ASTHMA CONTROL TEST

ASTHMA CONTROL TEST

INTRODUCTION
There is a major gap between what can be achieved with modern asthma management
sand what is currently being achieved. One of the main reasons for this is a lack of recognition of
asthma control and the requirement for more effective treatmentit is only through identifying
those patients with uncontrolled asthma that appropriate treatment will be prescribed. In part, the
difficulty in the assessment of control relates to the lack of a clear therapeutic target in asthma.
This contrasts with other chronic diseases such as hypertension or diabetes where treatment is
prescribed in order to achieve a definite therapeutic target. One approach to this difficulty is to
develop a simple test which is a screening tool to identify patients with poorly controlled asthma.
The Asthma Control Test (ACT) has been developed and validated for this purpose. It involves
patients completing a simple written questionnaire of 5 questions, from which a score (out of 25)
is obtained. It has been shown that the ACT is a simple, quick and accurate tool for assessing
asthma control and it has been shown to be responsive to changes in asthma control over time. It
can easily be incorporated into the routine assessment of patients with asthma and enable busy
healthcare professionals to more easily identify patients whose asthma control can be improved,
enabling changes to their management to be made and there by improve outcomes.(1)

DEFINITION
Asthma is a chronic respiratory disease that is mainly managed in primary care setting. In
the global initiative for asthma (GINA) 2006 guideline, achieving and maintaining clinical
control is highlighted as the goal asthma management. So far in China, an effective and
convenient means for evaluating asthma control has not been available in primary care settings,
especially in places where in spirometry is unavailable. In 2004, Nathan et al developed an easy
assessment tool for asthma control, know as the asthma control test (ACT).(2)

ASTHMA CONTROL TEST

MATERIAL AND METHODS

Study Population
Participants were recruited from the outpatients of the asthma department of the Amalia
Fleming general hospital in Athens, Greece, from January to July 2009 specified exclusion
criteria were chronic obstructive pulmonary disease (COPD),cardiovascular disease, neurological
disorders, physical disability, and inability to comprehend or complete questionnaires in Greek.
Data from 100 (n = 100 asthma outpatient (21 men and 79 women),aged from 18 to 80 years
(mean = 49.98,SD = 16.87), were used for the purposes of the present study. All patients,
clinically diagnosed according to the GINA, had at least a 12% improvement in FEV 1 after
inhalation of 200-400 g of Albutamol and were symptomatic during the past 12 months, under
a specialists care, and under controlled medications including inhaled glucocosticosteroids,
long-acting inhaled 2-agonist, and other medication according to GINA. With reference asthma
severity, 58 patients suffered from mild asthma, 32 patients had moderate asthma, and 10 patients
had severe asthma. Twenty patients aged 20-47 years were current smoker, 72 patients aged 1880 years were no smoker, and 8 patients aged 28-74 years were ex-smoker. Sixty-three patients
had asthma for more than 8 years. According to BMI, 44 patients were normal/underweight
(BMI<25 kg/m2), 34 were overweight, and 22 were obese.
The study protocol was approved by the Research Ehics Committee of the Amalia
Fleming General Hospital while the informed consent from was signed by all participants.(3)

THE ASTHMA CONTROL TEST (ACT)

A simple 5-question test for asthma has been developed and validated in several studies.
The ACT was initially developed in a study which looked at 22 of the most common questions
that doctors ask when talking to patients about asthma control, with 5 questions standing out as
being the most accurate predictors. The 5 questions take less than a minute to answer and can be
asked by the health care professional or the patient can complete the test themselves. There is a
score of 15 for each question, and an overall score in the range of 525, with low scores

ASTHMA CONTROL TEST

corresponding to a high level of symptoms and therefore poor asthma control. Studies have shown
that the ACT score effectively discriminates between patients who differ in asthma control, is
responsive to changes in control, and can discriminate between groups of patients in different lung
function ranges. The ACT score is highly effective as a screen for uncontrolled asthma and can
correctly predict GINA-defined partly controlled or uncontrolled asthma in over 90% of cases. A
score of 2025 means that a patients asthma is controlled. A score of 15-19 means that it may be
possible to increase the level of asthma control and a full review of the treatment plan, including
education on inhaler technique and the important of compliance with treatment, is warranted. A
score of 14 or less indicates that asthma is poorly or not controlled and that an urgent review of
and changes to the patients management are needed. Although there are no randomised studies
that demonstrate that use of the ACT translates into better asthma control, its use is highly likely
to improve patient outcomes as asthma therapy can be confidently adjusted up if control is
demonstrated to be poor. (1)
RESULTS
Revision of the questionnaire
The cognitive debriefing showed that most patients understood four of the five question.
However, the fourth question caused confusion as it asked rescue medication usage but
some patients answered about preventive medication.
Characteristics of study patients
A total 360 patients were invite to participate in the study; 323 (90%)of mean age 36
years (range 12-80) agreed to participate. Females comprised 57% of the participants
with a mean percentage predicted FEV 1 and PEF of 86% and 88,6%, respectively, and
mean ACT score of 20,5. Other characteristics are described in table 1, in which GINA
stage 3 is prominent (28%), but in general the patients were equally distributed among
the four stage. Most of the patients were using preventive medication; the majority had
controlled asthma according to both GINA and ACT criteria and were continued on the
same treatment after their visit.
Responsiveneses of the ACT to specialist treatment modivication

ASTHMA CONTROL TEST

The ACT scores for groups receiving different asthma treatment decesions after medical
assessment are shown in Table 3. The mean Ac score was similar for those in whom
treatment was either maintained or stepped down (p=0,9) but much lower in those in
whom treatment was stepped up. There was a significant correlation beteween the ACT
score and asthma treatment modification (Spearmans r=-0,36, p<0,001).Relationship
between ACT score and %FEV1 and %PEF. The pearson coefficient between the ACT
score and %PEV1 was 0,35 (p<0,001) and between the ACT score and %PEF it was
0,26(p<0,001).

Reliabity and empire validity of the ACT

Cronbachs alpha was 0.83, indicating a high consistency among the answers to the five
question of the ACT questionnaire. The cut-off point the ACT in detecting GINA not
controlled asthma was 19, which yielded the largest AUC of 0.85 with a sensitivity of

ASTHMA CONTROL TEST

70%, specifity of 73%. PPV of 89%, NPV of 79%, positive LR of 9.6, negative LR of
0.3, and s correctly classified rate of 83%.
Agreement between ACT and GINA in classifying three levels of asthma control.
The kappa value was 0.55 ( table 2), indicating a moderate level of level of agreement
beyond chance between the two rating systems ( I=0.4-0.6). both rating system correctly
classifield 75% at three levels of asthma control. (4)

DISCUSSION

ASTHMA CONTROL TEST

Achieving and maintaining asthma control are fundamental elements of asthma

management. Practical tools are needed to assess asthma control in asthma management. Most
tools used to evaluate asthma control consider airflow obstruction as a criterion. However, this is
often very diffcult to perform in developing countries such as Vietnam because spirometers and
peak flow meters are not readily available. A tool is required that measures the multidimensional
nature of asthma control and that is easy and quick to administer and interpret in order to
facilitate the assessment of asthma control in clinical practice. The ACT has proved to be a valid
tool for this purpose in other settings.(4)

ASTHMA CONTROL TEST

CHILDHOOD ASTHMA CONTROL TEST

ASTHMA CONTROL TEST

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